dai policy 500.50.02 attachment aa: filing in hcr-grid6th column: forward original to - send...

Effective: 10/13/14

DAI Policy 500.50.02

Instructions: File all documents within a given file location (column #4) by date order. Exceptions

are listed on page 2 - 5 of this attachment. Please take a moment to become familiar with these

exceptions.

Consult with Central Medical Records ([email protected]) prior to filing any document in

the Health Care Record that is not listed in this Attachment.

1st Column: Form Number (#) – Forms officially issued by the State of Wisconsin include a number preceded by the

department/division that owns the form such as DOC, DPH (Division of Public Health) F (formally DDE used at

Wisconsin Resource Center). Some forms in the HCR were issued by Prison Health Services (PHS)/Corrections

Corporation of America (CCA) for inmates whose health care was provided by a private corporation or who were

previously housed out-of-state. Forms without a number appear in alphabetical order following the forms with

numbers.

Attachment AA: Filing in HCR-Grid

2nd

Column: Title – Name of the form. Helpful guidance to filing may be listed after the forms name.

This table directs the filing for all forms in the Health Care Record including the Medical Chart, Dental Record,

Medications Record, Psychological Records (Copies), Psychological Service Unit Record, Hemodialysis Chart

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6th Column: Forward original to - Send originals to department listed in this column for forms that are not to be filed

in the Health Care Record.

3rd

Column: Historical (Hist.) – An “X” in this column means that the form may be found in the location described, but

is no longer filed in the HCR, has been made obsolete, or the filing location within the HCR has changed. Forms with

a new location should be moved to the proper location. The former location will be in parentheses. Do not file forms

in former locations.

4th Column: File Location – Lists the section of the Chart in which a form is filed, or directs filing in the Dental Record,

Medications Record, Psychological Records (Copies), or the PSU Record or indicates if the form copy can be

shredded (see 6th Column to determine what department originals need to be sent to)

5th Column: Multi-Section PSU Record/Dental Record - Lists the section of a multi-sectioned PSU Record or Dental

Record in which a form is filed.

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Power of Attorney for Health Care, DPH-00085

Living Will (Declaration to Physicians), DPH-00060

Signature Verification, DOC -3326

Offender name labels – sheet

Problem List – File documents in the order listed below.

Problem List, DOC-3020 (current)

Medical Summary, DOC-3613

Patient Care Plans Divider – File keeping like documents together, intermixed with most recent on top.

Record of Immunizations, DOC-3218A

Advanced Directives Log, DOC-3391A

Data Base Divider – File documents in the order listed below.

Court Documents and Orders: Guardianship, Ch. 51 Commitment and others for treatment, etc.

Medical Appointments Off-site, DOC-3347

Onsite Appointment List

Emergency Care/Do Not Resuscitate Order (DNR), DPH-4763

Implementation of a Patient’s Advance Directive, DOC-3391

File Location Exceptions

Medical Chart

Right Side in front of Problem List Divider – File in the order listed below.

Medical Imaging Sleeve with Medical Imaging CD’s

TST and Review of Signs/Symptoms of Tuberculosis, DOC-3286

Durable Power of Attorney for Health Care, DOH-0085 (Name changed “Power of Attorney for Health Care”)

Dialysis Access History Log, DOC-3449 (Hemodialysis Record)

3 of 42

Transplant Evaluation Log, DOC-3718

Admission History and Physical Examination - Infirmary, DOC-3589

Annual Report for Known Positive TB Skin Test, F-20135

TB Summary Report - WRC

H1N1 Vaccination Screening Questionnaire, DOC-3611

Institutional Converter (obsolete)

Immunization TB/Record (Out of State)

Health Service Unit Admission Data Base, DOC-3405

Infirmary Discharge Summary, DOC-3573, or equivalent

Wisconsin Immunization Registry (print-out from website)

Examen De Admision/Cambio/Recepcion, DOC-3002S (obsoblete)

Medical Admission Evaluation, F-25237

Admission Data Base-Hemodialysis, DOC-3405A (Hemodialysis Record)

Note: file screenings listed below in chronological order keeping like documents together.

Clinical Screening/Evaluation Summary and Recommendations, DOC-1417 (obsolete)

Infirmary Admission – Nurse to Nurse Report, DOC-3550 (obsolete)

Initial Entrance Screening, F-25644

Initial Health Screening Form, CCA-13-50A

Initial Health Screening Form, CCA-13-16A

Initial Medical Screening, PHS-CC 040 and CCA

Inmate/Resident Initial and Annual Symptom Screening, CCA-13-87E

Jail Contract: Inmate Medical Screening Form

Intake/Transfer/Receiving Screening, DOC-3002 (obsolete)

Jail Contract: Medical/Booking Questions

Receiving Medical Screening, PHS

TCI Intake Forms (no longer used)

4 of 42

Intake Medical Clearance Questionnaire, DOC-3636

Nursing Admisson Assessment - Infirmary, DOC-3635

Assessment – Cardiovascular Risk, F-26142A

Texas Uniform Health Status Update

Inmate Health Appraisal Form, CCA-13-16C

Transfer Screening, DOC-3532

Transfer Screening Form, CCA-13-86A

Note: file histories listed below in chronological order keeping like documents together.

Folstein Mini-Mental State Exam (MMSE), DOC-3539

Assessment-Admitting Physician, F-25507A

Data Base - Medical, F-21248

Initial Health Assessment and Medical History, F-24013B

Intake Screening/Medical History or El Chequeo De Entrada/Historia Medica, DOC-3018

Note: file assessments listed below in chronological order keeping like documents together.

Inmate/Resident Health Appraisal Form, CCA-13-40A

Physical Exam (Male), DOC-3019 or F2-4013A

Annual Review

Nutrition History and Assessment (if Dietician Consult ordered) (WRC) F-21097

WRC Intake Assessment (obsolete)

Note: file physical exams listed below in chronological order keeping like documents together.

Health Evaluation, CCA

Asthma Assessment, DOC-3443

Cardiovascular Risk Assessment, DOC-3466 (obsolete 2/08)

Initial Nursing Assessment, F-21250

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Physical Exam (Female), DOC-3019A

Note: file medical classifications listed below in chronological order keeping like documents together.

Medical Classification Report, DOC-3050

Medical Clearance for Programs at Facilities Without a HSU on-site (name change), DOC-3500

Medical Clearance Assessment for Challenge Incarceration Program (CIP), DOC-3500

Health Service Classification

Primary Care-Initial Physical Exam, F-00578A

Out of State Health Screening Checklist, CCA

Security Condition Report, DOC-3396 (obsolete 1/02)

Medical Clearance for Treatment Alternative Program (TAP), DOC-3500B

Medical Clearance for County Jails, DOC-3500A

Note: file diets listed below intermixed in chronological order.

Diet Flow Chart (if special diet ordered), F-21095

Diet Order Acknowledgment - Male, DOC-1836

Diet Order Change, DDE-1095A (obsolete 07/07)

Diet Order Acknowledgment - Female, DOC-1835A

Food Allergy/ Intolerance Diet Interview, DOC-3462 (obsolete)

Medical Diet Order

Modified Diet Consent/Refusal, DOC-3341

Modified Diet Order, DOC-3334 or F-25944

Therapeutic Diet Request, CCA-13-85A

Food Allergy/Intolerance Diet Interview, DOC-3518

WCCS Offender Intake TB Screening Tool, DOC-3425

Audiogram, DOC-3149

Offender Hepatitis B Vaccination Medical History, DOC-3400

6 of 42

Medication Treatment Record, DOC-3026 (Dialysis Records Only)

Non-Formulary Psychotropic Drug Request, DOC-3482A

PRN Medication Notes, DOC-3393

Medication Refusal and Compliance Monitoring (MSMU-SEG), DOC-3537A

Medication Divider - File documents in the order listed below keeping documents with the same DOC form number

together with most recent on top.

Discharge Medication Request, DOC-3397

Hemodialysis Medication List, DOC-3513 (Hemodialysis Record)

History and Evaluation for Individuals with Significant Reaction to PPD’s, DOC-3029

Tuberculosis Questionnaire

HIV Antibody Screening, DOC-3292 (obsolete)

HIV Positive Offender Profile, DOC-3283 (obsolete 4/07)

Dyskinesia Identification, F-24214

Patient Medication Profile, DOC-3034

Non-Formulary Drug Request (Other than Psychotropics), DOC-3482

Dental Record

Quetiapine and Olanzapine Drug Request, DOC-3482B

Restricted Psychotropic Drug Verification, DOC-3547

Stimulant and Atomoxetine Drug Requst, DOC-3482C

Medication Administration Record (Dialysis Records Only)

New Stimulant Request, DOC-3463 (obsolete)

Strattera (Atomoxetine) Request, DOC-3463A (obsolete)

Medical History (Prongs Inside Front Cover)

File documents by type in the order listed below and in date order with most recent on top within each type.

Health History for Dental Practice, DOC-3018B or DOC-3018BS

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NOTE: Keep all DJC documents together with Red cover sheet.

.

Intake Screening/Medical History, DOC-3018 or DOC-3018S

Activation/De-Activation of Power of Attorney for Health Care, DOC-3614

Ackonwledgment of Revocation of Power of Attorney for Health Care, DOC-3615

Notification of Guardianship/Activated Power of Attorney for Health Care, DOC-3563

Health History Update, DOC-3018A

File documents by type in the order listed below and in date order with most recent on top within each type.

Authorization and Consent to Surgery and Drug Administration, DOC-3367 or DOC-3367S

Consent for Orthodontic Treatment for Adults, DOC-3402

Consents/Authorizations/DJC Documents (Inside Back Cover Prongs)

Authorization and Consent for Root Canal Treatment (Endodontics) and Drug Administration, DOC-3414 or DOC-3414S

Informed Consent for the Treatment of Obstructive Sleep Apnea with Oral Appliances, DOC-3627 or DOC 3627S

Authorization and Consent for Dental Treatment, DOC-3442 or DOC-3442S

Consent/Refusal for Dental Services, F-21504

Consent for Orthodontic Treatment for Juveniles, DOC-3403 or DOC-3403S

Consent for Referral of Orthodontic Treatment, DOC-3404

Informed Consent Relating to Risks Associated with use of Oral Bisphosphonate, DOC-3593 or DOC-3593S

Authorization and Consent to Surgery and Drug Administration for Juveniles, DOC-3417 or DOC-3417S

Authorization and Consent for Root Canal Treatment (Endodontics) and Drug Administration-Juveniles, DOC-3416 or DOC-3416S

8 of 42

1st 2nd3rd

4th 5th 6th

Form # TitleHist

File LocationMulti-Section PSU or

DSU RecordForward Original to

0007 Offender Face Sheet - obsolete- not filed in chart X (Shred Copy) Shred

0009 Adult Conduct Reports - not filed in chart X (Shred Copy) Security

0027 Placement/Review of Patient In Observation

Orig. - Miscellaneous -for

medical observation or

PSU Record - for MH

Placements, copy -

Psychological Records

Observation/ Restraint/

Seg Reviews

0028 Notice of Review of Observation Status PSU Record


Seg Reviews

0030

Review of Offender in Segregation/Disciplinary Separation/

Administrative Confinement PSU Record


Seg Reviews

0045 Temporary Release - not filed in chart (Shred Copy) Records Office

0090 Chronological Log PSU Record Restricted Access

0097 Hospital Stay - not filed in chart (Shred Copy) Records Office

0098 Incident Reports - obsolete X (PSU Record) (Restricted Access) Security Office

0098 A Accident Report - not filed in chart (Shred Copy) Security Office

0111 Review of Placement of Offender in RestraintsCorrespondence or PSU

Record


Seg Reviews

0112 Observation of Offender - not filed in chart (Shred Copy) Security Office

0192 Notification of Sentence Data - not filed in chart (Shred Copy) Records Office

0223 Psychological Services Report

orig. - PSU Record, copy

- Psychological Records

(Copies) Psychological Reports

0237 Property Receipt/DispositionConsents/ Refusals or

Optical Sleeve

0618 County Jail Report - DCI Sheriff Letter

PSU Record - if revison

date is before 8/2007;

shred if after

Legal Documents/

Consents/ Outside

Reports

0643 Interview/Information Request (when responded to by HSU) Patient Request Folder

0654 Psychological Services Chronological File Entry PSU Record Psychological Reports

0851 Offender Emergency and Signature Verification - not filed in chart (Shred Copy) Social Service File

1004 Special Handling of Offender - not filed in chart (Shred Copy) Security Office

1121 Notice of Release - not filed in chart (Shred Copy) Legal File

1160 Record Request Response Consents/ Refusals

1163 A

Authorization For Use and Disclosure of PHI (first document under

divider if in effect)Consents/ Refusals or

PSU Record

Legal Documents/

Consents/ Outside

Reports

1163 AS

Autorizacion Para la Utilizacion Y Divulgacion De Informacion

Protegida Sobre la Halud (PHI)Consents/ Refusals or

PSU Record

Legal Documents/

Consents/ Outside

Reports

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4th 5th 6th

Form # TitleHist



1163 K Ch. 980 Authorization for Disclosure of AODA Information PSU Record

Legal Documents/

Consents/ Outside

Reports

1163 R

Revocation of Authorization for Use and Disclosure of Protected

Health InformationConsents/ Refusals or

PSU Record

Legal Documents/

Consents/ Outside

Reports

1345 Transfer Hold - Inmate - obsolete - not filed in chart X (Shred Copy) Records Office

1408 Offender Work Placement - not filed in chart (Shred Copy) Social Service File

1417

Clinical Screening/ Evaluation Summary and Recommendations -

obsolete X (Data Base)

1423 Sex Offender Program Report PSU Record SOT/Ch.980

1477

TTT Extended Visitation Authorization for Medical Treatment - not

filed in chart (Shred Copy) Gatehouse

1478 TTT Extended Visitation Child Medical Information - not filed in chart (Shred Copy) HSU

1479 Review of Mental Health Placement PSU Record

Referrals/ Screening/

Contacts

1490

End of Confinement Review Board (ECRB) Case Review Summary

and Disposition (copy) PSU Record SOT/Ch.980

1577 Sex Offender Assessment Report PSU Record SOT/Ch.980

1577 A Sex Offender Assessment Report - Abbreviated PSU Record SOT/Ch.980

1770 Daily Self-Harm Assessment PSU Record


Seg Reviews

1836 Diet Order Acknowledgment - Male Data Base

1836 A Diet Order Acknowledgment - Female Data Base

1843 Conduct Report - DJC PSU Record Restricted Access

1846 Incident Report - DJC PSU Record Restricted Access

1923

Limits of Confidentiality Regarding Information Rendered to

Treatment Staff PSU Record

Legal Documents/

Consents/ Outside

Reports

1950 Revocation Summary - not filed here X (PSU Record) (Restricted Access)

1980 Inter-Institution Transfer Summary PSU Record


Contacts

2056 Mental Health Screen for Wisconsin Secure Program Facility PSU Record Restricted Access

2056 A WSPF Brief Mental Health Screen for TLU/ Seg - obsolete X (PSU Record) (Restricted Access)

2057 Bifurcated TIS Computation - not filed in chart (Shred Copy) Shred

2068 Informed Consent for Pharmacological Treatment - not filed in chart (Shred Copy)

RCI HSU - Label as

PTSO File

2074 Medical Alert Wristband Acceptance/Refusal Consents/ Refusals

10 of 42

1st 2nd3rd

4th 5th 6th

Form # TitleHist



2077 Health Transfer Summary Correspondence

2097 Self-Harm Assessment PSU Record


Seg Reviews

2098

Initial Placement in Observation Status & Notice of Rights and

Appeal PSU Record


Seg Reviews

2099 Notice of Review for Continued Observation PSU Record


Seg Reviews

2112 New Psychiatric Referral Correspondence

2115 Psychotropic Review - Report on Youth Progress



(Copies)


Contacts

2144 Transporting Officer Questionnaire (TOQ)

PSU Record and


(Copies)


Contacts

2145 Intake Screening - Juvenile Correctional Institution

PSU Record and


(Copies)


Contacts

2148 Review of Placement in Observation Status PSU Record


Seg Reviews

2170 Short Term Absence Screening - Lincoln Hills School

PSU Record and


(Copies)


Contacts

2272 Physician Consultation: PRIDE Referrals - copy Correspondence

2273 Psychiatrist Consultation for Pride Referrals - copy Psychiatric Services

2295 Special Purpose Evaluation Report -copy PSU Record SOT/Ch.980

2296 Minnesota Sex Offender Screening Tool (MnSOST-R) PSU Record SOT/Ch.980

2309 Certification of RecordsConsents/ Refusals or

PSU Record

Legal Documents/

Consents/ Outside

Reports

2363 Reentry Pre-Release Competency Checklist - Male (Shred Copy)

2364

Static-99/Rapid Risk Assessment for Sexual Offense Recidivism

(RRASOR) Scoring Sheet PSU Record SOT/Ch.980

2380

Sex Offender Assessment Program (SOAP) Re-Evaluation Request -

Differing Opinions Review Process (DORP) PSU Record SOT/Ch.980

2381

Sex Offender Assessment Program (SOAP) Re-Evaluation Request:

SOAP Response - Differing Opinions Review Process (DORP) PSU Record SOT/Ch.980

2427 Offender Visitor Review Removal/ Denial/ Approval PSU Record


Contacts

2439 Primary Program Status, Participation/ Refusal/ Withdrawal (copy) PSU Record

Legal Documents/

Consents/ Outside

Reports

2456 Sex Offender Treatment Reoffense Prevention Plan SO4 Programs PSU Record SOT/Ch.980

2456 A Sex Offender Treatment Reoffense Prevention Plan SO2 Programs PSU Record SOT/Ch.980

2464 Sex offender Treatment Interview Decision PSU Record SOT/Ch.980

2465 Informed Consent: Sex Offender Treatment Evaluation PSU Record SOT/Ch.980

11 of 42

1st 2nd3rd

4th 5th 6th

Form # TitleHist



2469 Intake Suicide History Questionnaire PSU Record


Contacts

2473 Sex Offender Treatment Evaluation: Attitudes Questionnaire PSU Record SOT/Ch.980

2474 Brief Sexual History Questionnaire PSU Record SOT/Ch.980

2507 Informed Consent Sex Offender Treatment PSU Record

Legal Documents/

Consents/ Outside

Reports

2508 Sex Offender Treatment Contract PSU Record SOT/Ch.980

2510 Sex Offender Treatment Progress Notes PSU Record SOT/Ch.980

2530 Reasonable Modification/ Accommodation Request Correspondence

2540 Family Therapy Referral PSU Record


Contacts

3001 Off-Site Service Request and Report - file location changed X

Consultations or (Dental

Record)

(Consents/

Authorizations/ DJC

Documents)

3001 Off-Site Service Request and ReportConsultations or Dental

Record Correspondence

3002 Intake/Transfer/Receiving Screening - obsolete X (Data Base)

3002 S Examen De Admision/Cambio/Recepcion Data Base

3003 Health Summary Correspondence

3011 Fee for Copies of Health Care Records (file with Authorization form)Consents/Refusals or

PSU Record

Legal Documents/

Consents/ Outside

Reports

3018 Intake Screening/ Medical HistoryOriginal - Data Base,

Copy - Dental Record Medical History

3018 A Health History Update - Dental Services Dental Record Medical History

3018 AS Actualizacion De Historia De Salud (Servicios Dentales) Dental Record Medical History

3018 B Health History for Dental Practice Dental Record Medical History

3018 BS Historial De Saulud Para la Practica Dental Dental Record Medical History

3018 S El Chequeo De Entrada/ Historia MedicaOriginal - Data Base,

Copy - Dental Record Medical History

3019 Physical Exam-Male Data Base

3019 A Physical Exam-Female Data Base

3020 Problem List

Problem List - current;

Miscellaneous - not

current

3021 Progress Notes Progress Notes

3021 A Dialysis Progress Notes Progress Notes

12 of 42

1st 2nd3rd

4th 5th 6th

Form # TitleHist



3021 B Psychiatric Progress Notes (first document under divider) Psychiatric Services

3021 C Psychology Progress Notes - Taycheedah Correctional Institution PSU Record


Contacts

3021 D Psychology Progress Notes (Noncontact) PSU Record


Contacts

3022 Infirmary Progress Notes Progress Notes

3022 A Speech Therapy Progress Notes Consultations

3023 Prescriber's Orders Prescriber's Orders

3023 A Prescriber's Orders-Standard Admission Orders Prescriber's Orders

3023 B Prescriber's Orders-Standard Orders-Youth Prescriber's Orders

3023 C Prescriber's Orders- Infirmary Adm. Prescriber's Orders

3023 D Prescriber's Orders-Standard Orders-Hemodialysis Prescriber's Orders

3023 E Prescriber's Orders-Standard Orders-Short Term Admission Prescriber's Orders

3023 F Prescriber's Orders-Standard Orders-ATR/FDOATP Admission Prescriber's Orders

3023 G Prescriber's Orders-Standard Orders-Opiate/Methadone Withdrawal Prescriber's Orders

3023 H Prescriber's Orders-Standard Orders- Alcohol Withdrawal Prescriber's Orders

3023 J

Prescriber's Orders-(Venlafaxine ER Conversion)-Nursing Delegated

Standard Orders Prescriber's Orders

3023 K Prescriber's Orders-PCA Infirmary Prescriber's Orders

3023 Q Prescriber's Orders - Standard Orders for Suspected MRSA Infection Prescriber's Orders

3023 R Prescriber’s Orders- Standing Orders for Suspected H1N1 Prescriber's Orders

3023 T Palliative Care Admission Orders Prescriber's Orders

3023 U

Prescriber's Orders (Omeprazole to Pantoprazole Conversion) -

Nursing Delegated Standard Orders Prescriber's Orders

3023 V

Prescriber's Orders - Lantus Insulin (glargine) to NPH Conversion -

Nursing Delegated Standard orders Prescriber's Orders

3023 W Prescriber's Orders - Standard Orders - Peritoneal Dialysis Prescriber's Orders

3024 Flow Sheet Flow Sheets

3024 A Wound Care Initial Assessment Flow Sheets

3024 B Wound Care Flow Sheet Flow Sheets

13 of 42

1st 2nd3rd

4th 5th 6th

Form # TitleHist



3026 Medication/ Treatment Record Medications Record

3026 A IV Administration Record Medications

3027 Physician's Plan of Care - obsolete X (Patient Care Plan)

3027 A Nursing Plan for Patient Care - obsolete X (Patient Care Plan)

3028 Authorization for Medical and/ or Surgical Treatment Consents/ Refusals

3028 S Autorizacion Para Tratamiento Medico Y/O Sirugia Consents/ Refusals

3029

History and Evaluation for Individuals with Significant Reaction to

Tuberculin Skin Test Data Base

3032 INH and RPT Treatment Flow Sheet Flow Sheets

3034 Patient Medication Profile Medications

3035 Health Service Request and Copayment Disbursement Authorization Patient Request Folder

3035 A DJC Health Service Request Patient Request Folder

3035 AS

Solicitud De Servicio De Salud De La Division De Correcciones De

Menores (DJC) Patient Request Folder

3035 B Psychological Service Requests

PSU Record or Patient

Request Folder (when

responding to by HSU) Inmate Correspondence

3035 BS Solicitud De Servicio De Psicologia PSU Record Inmate Correspondence

3035 C Medication/Medical Supply Refill Request Patient Request Folder

3035 CS Solicitud De Reposicion De Medicamentos/ Suminstros Medicos Patient Request Folder

3035 D Youth Request for Psychological Services PSU Record Inmate Correspondence

3035 DS Solicitud De Servicios Psicologicos Para Jovenes PSU Record Inmate Correspondence

3035 S

Solicitud De Servicios De Salud Y Autorizacion Para El Desembolso

Del Copago Patient Request Folder

3040 Treatment Notes Dental Record Treatment Notes

3040

Diagnosis and Treatment Continued - name changed, file location

changed X (Dental Record) (Diagnosis/ Treatment)

3040 A Diagnosis - Treatment - obsolete X (Dental Record) (Diagnosis/ Treatment)

3040 E Examination (sticker placed on 3040 or 3040A) - obsolete X (Dental Record) (Diagnosis/ Treatment)

3040 H Hygiene (sticker placed on 3040 or 3040A) -file location changed X (Dental Record) (Diagnosis/ Treatment)

3040 H Hygiene (label placed on 3040) Dental Record Treatment Notes

14 of 42

1st 2nd3rd

4th 5th 6th

Form # TitleHist



3040 R Restorative (label placed on 3040) Dental Record Treatment Notes

3040 R Restorative (sticker placed on 3040 or 3040A) - file location changed X (Dental Record) (Diagnosis/ Treatment)

3040 X Extraction (label placed on 3040) Dental Record Treatment Notes

3040 X Extraction (sticker placed on 3040 or 3040A) - file location changed X (Dental Record) (Diagnosis/ Treatment)

3042 Dental Examination and Record Chart Dental Record Oral Examination

3042 Dental Examination and Record Chart-file location changed X (Dental Record) (Diagnosis/ Treatment)

3050 Medical Classification Data Base

3052 Dental Classification Report Dental Record Correspondence

3054

Eye care Examination (first document under divider in chronological

order) Optical

3054 A Chronological Record of Eye Care Case Management Optical

3121 Insulin Record Flow Sheets

3143 Laboratory Procedures Laboratory Results

3143 A Laboratory Procedures Laboratory Results

3149 Audiogram Data Base

3151 Pregnancy Status Notification Correspondence

3157 Birth Notification - obsolete X (Correspondence)

3175 Health Services Appointment Notice - no longer filed in chart X (Shred Copy)

3181 Medical Excuse - obsolete X (Correspondence)

3183 Referral for On-Site Medical/ Mental Health ServicesCorrespondence or PSU

Record


Contacts

3200 Optical Prescription Optical Sleeve

3218 A Record of Immunizations - File as first document Data Base

3220 Refusal of Recommended Health CareConsents/ Refusals or

PSU Record

Legal Documents/

Consents/ Outside

Reports

3220

Refusal of Recommended Health Care - no longer filed in the Dental

Record X

Consents/ Refusals or

PSU Record or (Dental

Record)

Legal Documents/

Consents/ Outside

Reports or (Consents/

Authorizations)

3220 S Rechazo Del Tratamiento De Salud Recomendado Consents/ Refusals

3220 S

Rechazo Del Tratamiento De Salud Recomendado - no longer filed

in the Dental Record X

Consents/ Refusals or

(Dental Record)

(Consents/

Authorizations/ DJC

Documents)

15 of 42

1st 2nd3rd

4th 5th 6th

Form # TitleHist



3226 Consent for DNA Paternity Case Consents/ Refusals

3226 S

Consentimiento Para Examen De And Con Proposito De Establecer

Paternidad Consents/ Refusals

3246 Inventory ControlledSubstance - not filed in chart X (Shred Copy) HSU

3246 B Dea Controlled Substance Perpetual Inventory Point of Delivery Originating facility

3263 Consent/ Refusal to test for HIV Antibody Consents/ Refusals

3263 S

Consentimiento/ Rehuso A Participar En La Prueba De Vih-Anti-

Organos Consents/ Refusals

3283 HIV Positive Offender Profile - obsolete X (Data Base)

3286

Annual Tuberculosis and Health Maintenance Screening - File after

DOC-3218A (second document) Data Base

3292 HIV Antibody Screening - obsolete X (Data Base)

3314 Health Summary - DJC Correspondence

3326 Signature VerificationRight Side in front of

Problem List

3332 B Medical Restrictions/ Special Needs Correspondence

3332 BS Restricciones Medicas/ Necesidades Especiales Correspondence

3334 Modified Diet Order Data Base

3335 Request for PHI for Ongoing TreatmentCorrespondence, Dental

Record or PSU Record

Correspondence or

Inmate Correspondence

3335 A Request for PHI Regarding Death of a PatientCorrespondence, Dental


Correspondence or


3336 Information for On-Call Nurse - obsolete X (Progress Notes)

3338 Health Assessment of Patient in Mechanical Restraints Flow Sheets

3340 Medication Error Report - not filed in chart (Shred Copy) Central Pharmacy

3341 Modified Diet Consent/Refusal Data Base

3341S Consentimiento/Rechazo A Dieta Modificada Data Base

3342 Disclosure of PHI Without Patient AuthorizationMiscellaneous or PSU

Record

Legal Documents/

Consents/ Outside

Reports

3347 Medical Appointments Off-siteRight Side in front of

Problem List

3348 Medication Log-Officer -obsolete X (Medications Record)

3359 Agent Notification of Tuberculosis Infection or Disease Correspondence

16 of 42

1st 2nd3rd

4th 5th 6th

Form # TitleHist



3367 Authorization and Consent to Surgery and Drug Administration Dental Record

Consents/ Authorizations/

DJC Documents

3367 S

Authorization Y Consentimiento Para Intervencion Quirurgica Y

Administracion De Medicamentos Dental Record


DJC Documents

3373 Medical Restraint Flow Sheet - name change X (Flow Sheets)

3373 Protective Restraint Flow Sheet Flow Sheets

3374 Flow Sheet - Vitals Flow Sheets

3377 X-Ray Consent - Female Offender - obsolete X (Consents/ Refusals)

3378 HIV Positive Flow Sheet Flow Sheets

3383 X-Ray Order Form - obsolete X (Medical Imaging)

3385 Ophthalmology Consultation Request and Report Consultations

3387 Health Screening-DJC Correspondence

3388 Health & Psychological Rounds In Segregation/Security LogFlow Sheets or PSU

Record


Contacts

3391 Activation/Deactivation of Declaration of Physicians

Active - Right Side in

front of Problem List;

Deactivated -

3391 A Advanced Directives LogRight Side in front of

Problem List

3392

Dental Service Requests and Copayment Disbursement

Authorization Dental Record Dental Service Requests

3392

Dental Service Requests and Copayment Disbursement

Authorization - file location changed X (Dental Record) (Correspondence)

3392 S

Solicitud De Servicio Dental Y Autorization Para El Desembolso Del

Copago Dental Record Dental Service Requests

3392 S

Solicitud De Servicio Dental Y Autorization Para El Desembolso Del

Copago - file location changed X (Dental Record) (Correspondence)

3393 PRN Medication Notes Medications

3394 Patient Assessment Flow Sheets

3394 A Patient Assessment Record - Continued - obsolete X Flow Sheets

3394C Patient Assessment Record - obsolete X (Progress Notes)

3395 Patient Care Flow Sheet Flow Sheets

3395 A Patient Special Procedure Flow Sheet Flow Sheets

3396 Security Condition Report - obsolete X (Data Base)

3397 Discharge Medication Request Medications

17 of 42

1st 2nd3rd

4th 5th 6th

Form # TitleHist



3397S Solicitud De Medicacion Para Descarga De Prison Medications

3400 Offender Hepatitis B Vaccination Medical History Data Base

3401 Informed Consent for Psychotropic Medication Consents/ Refusals

3401 A

Informed Consent/Refusal - Psychotropic Medication - Antianxiety -

obsolete X (Consents/ Refusals)

3401 AS

Consentimiento/ Rechazo Informado - Medicamentos Psicotropicos

Contra La Ansiedad - obsolete X (Consents/ Refusals)

3401 B

Informed Consent/Refusal - Psychotropic Medication -

Anticonvulsant Mood Stabilizer - obsolete X (Consents/ Refusals)

3401 BS


Anticonvulsivos/ Estabilizadores Del Animo - obsolete X (Consents/ Refusals)

3401 C

Informed Consent/Refusal - Psychotropic Medication - Heterocyclic

Antidepressants - obsolete X (Consents/ Refusals)

3401 CS

Consentimiento/ Rechazo Informado - Medicamentos Psicotropicos -

Antidepresivos Tricilicos - obsolete X (Consents/ Refusals)

3401 D

Informed Consent/Refusal - Psychotropic Medication - Atypical


3401 DS


Anditdepresivos Atipicos - obsolete X (Consents/ Refusals)

3401 E

Informed Consent/Refusal - Psychotropic Medication - Serotonin


3401 ES


Antidepresivos/ Serotonina - obsolete X (Consents/ Refusals)

3401 F

Informed Consent/Refusal - Psychotropic Medication - Alpha Agonist

- obsolete X (Consents/ Refusals)

3401 FS


Agonistas Alfa - obsolete X (Consents/ Refusals)

3401 G

Informed Consent/Refusal - Psychotropic Medication - Antipsychotic

Agents - obsolete X (Consents/ Refusals)

3401 GS


Agentes Antipsicoticos - obsolete X (Consents/ Refusals)

3401 H

Informed Consent/Refusal - Psychotropic Medication - Beta-

Adrenergic Blocker - obsolete X (Consents/ Refusals)

3401 HS


Bloqueadores Beta-Adrenergicos - obsolete X (Consents/ Refusals)

3401 J

Informed Consent/Refusal - Psychotropic Medication - Central

Nervous System Stimulants - obsolete X (Consents/ Refusals)

3401 JS


Estimulantes Del Sistema Nervioso Central - obsolete X (Consents/ Refusals)

3401 K

Informed Consent/Refusal - Psychotropic Medication - Mood

Stabilizing Agent - obsolete X (Consents/ Refusals)

3401 KS

Consentimeinto/ Rechazo Informado- Medicamentos Psicotropicos

Agents Estabilizadores Del Animo - obsolete X (Consents/ Refusals)

3401 L

Informed Consent/Refusal - Psychotropic Medication - Clozaril -


3401 LS


Clozaril - obsolete X (Consents/ Refusals)

18 of 42

1st 2nd3rd

4th 5th 6th

Form # TitleHist



3401 M

Informed Consent/Refusal - Psychotropic Medication -


3401 MS


Antidepresivos - obsolete X (Consents/ Refusals)

3401 N

Informed Consent/Refusal - Psychotropic Medication - Strattera -


3401 NS


Strattera - obsolete X (Consents/ Refusals)

3401 P

Informed Consent/Refusal - Non-Formulary - Psychotropic

Medication - Antipsychotic Agent - obsolete X (Consents/ Refusals)

3401 PS

Consentimiento/ Rechazo Informado - Medicamentos Psicotraopicos

Fuera Del Formulario Agent Antipsicotico - obsolete X (Consents/ Refusals)

3401 Q

Informed Consent/Refusal - Non-Formulary - Psychotropic

Medication - Anticonvulsant/Mood Stabilizer - obsolete X (Consents/ Refusals)

3401 QS


Fuera Del Formulario Anticonvulsivo/ Estabilizador Del Animo -


3401 R

Informed Consent/Refusal - Psychotropic Medication - Atypical

Antipsychotic Agents - obsolete X (Consents/ Refusals)

3401 RS


Agentes Antipsicoticos Atipicos - obsolete X (Consents/ Refusals)

3401 T Informed Consent/Refusal - Antihistamine - obsolete X (Consents/ Refusals)

3401 TS Consentimiento/ Rechazo Informado - Anthistamnico - obsolete X (Consents/ Refusals)

3401 U

Informed Consent/Refusal - Atypical Psychostimulant Modafinil -


3401 US

Conssentimiento/ Rechazo Informado- Psicoestimulate Atipico

Modafinilo - obsolete X (Consents/ Refusals)

3401S Consentiminento Informado Para medicamento Psicotropico Consents/ Refusals

3402 Consent for Orthodontic Treatment for Adults Dental Record

Consents/

Authorizations/DJC

Documents

3402 S Consentimiento De Adultos Para Tratamiento De Ortodoncia Dental Record

Consents/

Authorizations/DJC

Documents

3403 Consent for Orthodontic Treatment for Juveniles Dental Record


DJC Documents

3403 S Consentimiento Para El Tratamiento De Ortodoncia Para menores Dental Record


DJC Documents

3404 Consent for Referral of Orthodontic Treatment Dental Record


DJC Documents

3404S

Consentimiento Para La Referencia Para El Tratamiento De

Ortodoncia Dental Record


DJC Documents

3405 Admission Data Base - DCI Infirmary Data Base

3405 A Admission Data Base-Hemodialysis Data Base

3407 IV Flow Record Flow Sheets

3410 Record of Intake and Output - DCI Infirmary Flow Sheets

19 of 42

1st 2nd3rd

4th 5th 6th

Form # TitleHist



3411 Patient Care Conference Record Patient Care Plans

3413 Hemodialysis Kardex Miscellaneous

3414

Authorization and Consent for Root Canal Treatment (Endodontics)

and Drug Administration Dental Record


DJC Documents

3414 S

Autorizacion Y Consentiiento Para El Tratamiento De Conducto (

Endodocia) Y Para la Administracion De Medicamentos Dental Record


DJC Documents

3415 Physician's Telephone Consultation Progress Notes

3416

Authorization and Consent for Root Canal Treatment (Endodontics)

and Drug Administration for Juveniles Dental Record


DJC Documents

3416 S

Autorizacion y Consentimiento Para El Tratamiento De La Raiz De

Canal (Endodoncia) Y Administracion De Medicacion A Juveniles Dental Record


DJC Documents

3417

Authorization and Consent to Surgery and Drug Administration for

Juveniles Dental Record


DJC Documents

3417 S

Autorizacion Y Consentimiento Para Realizar Cirugias Y Administrar

Medicamentos A Menores Dental Record


DJC Documents

3421 Therapy Vitals Sheet Flow Sheets

3422 Renal Transplant Evaluation Dialysis Program Consultations

3423 Hemodialysis Treatment (first document under divider) Flow Sheets

3424 Chest Pain Assessment Encounter Progress Notes

3424 B Dizziness-Syncope Assessment Encounter - obsolete X (Progress Notes)

3424 C Dermatological Assessment Progress Notes

3424 D Headache Assessment Encounter - obsolete X (Progress Notes)

3424 E Headache Diary Flow Sheet Flow Sheets

3424 F Neurological Assessment Flow Sheet Flow Sheets

3425 WCCS Offender Intake TB Screening Tool Data Base

3428 HCV Treatment Evaluation Care Plan Patient Care Plans

3429 Consent/Refusal Hepatitis C Treatment X (Consents/ Refusals)

3429 A Consent/ Refusal Hepatitis C Treatment Genotype 1 Consents/ Refusals

3430 Hepatitis Monitoring Flow Sheet Flow Sheets

3431 Telemedicine Appointment Notice/Refusal Correspondence

3436

Prior Authorization for Non-Urgent Care - used for dental only - file

location changed X (Dental Record)

(Consents/

Authorizations/ DJC

Documents)

20 of 42

1st 2nd3rd

4th 5th 6th

Form # TitleHist



3436 Prior Authorization for Non-Urgent Care - used for dental only Dental Record Correspondence

3436 A Prior Authorization for Therapeutic Level of Care Consultations

3436 S Pre Autorizacion Para Cuidado Medico-No Urgente Dental Record Correspondence

3436 S

Pre Autorizacion Para Cuidado Medico-No Urgente- file location

changed X (Dental Record)

(Consents/

Authorizations/ DJC

Documents)

3437 Nurse's Telephone Consultation Progress Notes

3439 Diabetes Treatment Care Plan Patient Care Plans

3439 A Diabetic Annual Foot Examination Patient Care Plans

3440 Diabetic Education Care Plan - obsolete X (Patient Care Plan)

3441 Diabetic Log Flow Sheets

3441 A Staff Administered Insulin Log Medications

3442 Authorization and Consent for Dental Treatment Dental Record


DJC Documents

3442 S

Autorizacion Y Consentimiento Para El Tratamiento De higiene

Dental Dental Record


DJC Documents

3443 Asthma Assessment Data Base

3444 Asthma Treatment Care Plan Patient Care Plans

3445 Asthma Education Flow Sheet - obsolete X (Flow Sheets)

3446 Asthma Self-Management Care Plan Patient Care Plans

3449 Dialysis Access History LogRight Side in front of

Problem List

3450 Hunger Strike Initial Assessment Patient Care Plans

3450 A Hunger Strike PSU AssessmentPatient Care Plans or

PSU Record Psychological Reports

3451 Hunger Strike Care Plan Patient Care Plans

3452 Acknowledgement of Not Eating or Drinking Information Consents/ Refusals

3453 Hepatitis C Treatment Candidate, Psychiatrist Review Psychiatric Services

3459 Warfarin Anticoagulation Monitoring Care Plan Patient Care Plans

3462 Food Allergy / Intolerance Diet Interview - obsolete X (Data Base)

3463 New Stimulant Request - obsolete X (Medications)

21 of 42

1st 2nd3rd

4th 5th 6th

Form # TitleHist



3463 A Strattera (Atomoxetine) Request - obsolete X (Medications)

3464 Opioid Withdrawal Assessment Flow Sheets

3465 Selective Severity Assessment (SSA) Flow Sheets

3466 Cardiovascular Risk Assessment - obsolete X (Data Base)

3467 Hypertension Treatment Care Plan Adolescent Patient Care Plans

3468 Hypertension/ Dyslipidemia Treatment Care Plan-Adult Patient Care Plans

3472 Mental Health Screening Interview



(Copies)


Contacts

3472 A

Mental Health Screening Interview - Taycheedah Correctional

Institution



(Copies)


Contacts

3473 Psychological Services Clinical Contact



(Copies)


Contacts

3473 A Psychological Services Clinical Contact (Monitoring)



(Copies)


Contacts

3474 Psychologist Minimum Security Recommendation PSU Record


Contacts

3475

Bureau of Health Services Request for Restriction Approval- file

location changed X

Correspondence or

(Dental Record)

(Consents/

Authorizations/ DJC

Documents)

3475 Bureau of Health Services Request for Restriction ApprovalCorrespondence or

Dental Record

Laboratory/

Miscellaneous

3479 Infirmary PCA Flow Sheet Flow Sheets

3480 Self Harm Assessment

Original: PSU Record;

Copy: Psychological

Records (Copies)


Seg Reviews

3482 Non-Formulary Drug Request (Other than Psychotropics) Medications

3482 A Non-Formulary Psychotropic Drug Request Medications

3482 B Quetiapine and Olanzapine Drug Request Medications

3482 C Stimulant and Atomoxetine Drug Request Medications

3483 Consent/ Refusal for Recording & Imaging of PHI Consents/ Refusals

3483 A

Consent for Electronic Recording of Protected Health Information

(PHI)Consents/ Refusals or

PSU Record

Legal Documents/

Consents/ Outside

Reports

3483 AS

Consentmiento Para Grabacion Electronica De Informacion

Protegida De Salud (PHI)Consents/ Refusals or

PSU Record

Legal Documents/

Consents/ Outside

Reports

3483 S

Consentimiento/ Rechazo De Grabacion Y Grabacion De Imagen De

Informatcion Medica Protegida Consents/ Refusals

3484 Request for Amendment/Correction of PHI X

Correspondence or

Dental Record or PSU

Record

Correspondence or


3484 A

Request by Former Patient for Amendment/ Correction of Protected

Health Information (PHI)

Correspondence or


Record

Correspondence or


22 of 42

1st 2nd3rd

4th 5th 6th

Form # TitleHist



3486 DCI Hemodialysis Monthly Summary Progress Notes

3487 Request By Current Patient for Restriction on Use/Disclosure of PHICorrespondence, Dental


Correspondence Inmate

Correspondence

3487 A Request By Former Patient For Restriction on Use/Disclosure of PHICorrespondence, Dental


Correspondence,


3487 A Request by Former Patient for Restriction on Use/Disclosure of PHICorrespondence or PSU

Record or Dental Record

Inmate Correspondence,

Correspondence

3487 S Solicitud Para Restringir El Uso/ Divulgacion De PhiCorrespondence, Dental


Correspondence or


3488 Request for Alternative Communication of PHI

Correspondence or

Dental record or PSU

Record

Correspondence or


3488 S Solicitud Para Comunicacion Alternativa De PhiCorrespondence, PSU

Record or Dental Record

Correspondence or


3489 Request for Accounting of Disclosures of PHICorrespondence, Dental


Correspondence, Inmate

Correspondence

3489 S Solicitud De Contabilidad De las Divulgaciones De Phi Correspondence

3489 S Solicitud Para La Contabilidad De Las Divulgaciones Hechas De PhiCorrespondence, Dental


Correspondence, Inmate

Correspondence

3491 Acknowledgment of Receipt of Notice of DOC Privacy Practices Consents/ Refusals

3494 Abnormal Involuntary Movement Scale (AIMS) Psychiatric Services

3495 Musculoskeletal Evaluation Progress Notes

3496 Psychiatric Report

orig. - Psychiatric

Services, copy - PSU

Record Psychiatric Reports

3497 Special Purpose Evaluation Notice of Examination PSU Record

Legal Documents/

Consents/ Outside

Reports

3498

Informed Consent for Psychological Services Provided by Intern-

Student PSU Record

Legal Documents/

Consents/ Outside

Reports

3500

Medical Clearance Assessment for Challenge Incarceration Program

(CIP) Data Base

3500 A Medical Clearance for County Jails Data Base

3500 B Medical Clearance for Treatment Alternative Program (TAP) Data Base

3501 Gastrointestinal Assessment Encounter - obsolete X (Progress Notes)

3503 Psychological Services Intake File Review PSU Record


Contacts

3504 Infection Control: Patient and Employee Precautions Correspondence

3504 A Infection Control Notice - not filed in chart (Shred Copy) Housing Unit

3505 MRSA Case Tracking and Reporting Laboratory Results

3506 Psychological Services Session Note

PSU Record and


(Copies)


Contacts

23 of 42

1st 2nd3rd

4th 5th 6th

Form # TitleHist



3508

Notarized Statement for Access to Health Information Regarding a

Deceased PersonConsents/ Refusals or

PSU Record

Legal Documents/

Consents/ Outside

Reports

3509 Psychology Input for Hearing Officers PSU Record


Contacts

3509 A Psychology Input for Security Decisions - TCI PSU Record


Contacts

3510 Patient Care Plan Patient Care Plans

3511 PSU Treatment Plan

PSU Record and


(Copies) Psychological Reports

3512 Hemodialysis Laboratory Summary Laboratory Results

3513 Hemodialysis Medication List Medications

3515 Genitourinary Assessment Encounter - obsolete X (Progress Notes)

3516 Respiratory Assessment Encounter - obsolete X (Progress Notes)

3517 Trauma Assessment Encounter - obsolete X (Progress Notes)

3518 Food Allergy/Intolerance Diet Interview Data Base

3519 Dialysis Program Patient Care Conference Summary Evaluations Problem List

3520 Hemodialysis Patient Orientation Miscellaneous

3523 Class III Request for Partial Dentures - file location changed X (Dental Record)

(Consents/

Authorizations/ DJC

Documents)

3523 Class III Request for Partial Dentures Dental Record Correspondence

3527 Nutritional Monitor- file location changed. X (Miscellaneous)

3527 Nutritional Monitor Flow Sheets

3528 Change of Consultant Recommendations Consultations

3529 Mental Health Classification Worksheet - not filed in chart (Shred Copy)

Shred - after data is

entered

3530

Patient Instruction and Provider Documentation Hemodialysis Graft/

Fistula Miscellaneous

3531 Sleep Log PSU Record


Contacts

3532 Transfer Screening Data Base

3534 Palliative Care Program Patient Bill of Rights Consents/ Refusals

3534S Declaracion De Derechos Del Programa Paliativo Consents/ Refusals

3535

Patient Consent for Palliative Care Program and Request to

Discontinue Consents/ Refusals

24 of 42

1st 2nd3rd

4th 5th 6th

Form # TitleHist



3535 S

Solicitud Del/A Paciente Para Fin De Tratamiento/Cuidado Medico

Yo De Vida Solicitud Del/A Paciente Para Descontinuar

Participacion En Dicho Programa Consents/ Refusals

3536 HIV Care Plan Management Patient Care Plans

3537 A Controlled Medication Non-Adherence Medications

3538 Medication Education Log Medications

3539 Folstein Mini-Mental State Exam (MMSE) Data Base

3539 A Mini Mental Status Exam Flow Sheet Flow Sheets

3540 Monarch Special Management Unit Referral

PSU Record and


(Copies)


Contacts

3541 Mental Health Assessment Encounterorig. Progress Notes;

copy - PSU Record


Contacts

3544 Adult Informed Consent Psychotropic Medication - Clozaril Consents/ Refusals

3547 Restricted Psychotropic Drug Verification - obsolete X (Medications)

3550 Infirmary Admission - Nurse to Nurse Report - obsolete X (Data Base)

3551 HBV Evaluation and Review Care Plan Patient Care Plans

3554 Affidavit of Terminal Condition - copy Miscellaneous Attach to Court Doc.

3555 Hemodialysis Access Referral - New Access Consultations

3556 Hemodialysis Access Referral - Existing Access Consultations

3558 Physical/Occupational Therapy Service Agreement Consents/ Refusals

3559 Physical/Occupational Therapy Initial Evaluation Consultations

3560 Physical/Occupational Therapy Progress Notes Consultations

3561 Physical/Occupational Therapy Discharge Summary Consultations

3562 Request for Additional Physical/Occupational Therapy Consultations

3563 Notification regarding Guardianship of the Person

Right Side in front of

Problem List; Copy -


Medical History, Legal

Documents/Consents/

Outside Records

3564 Chronic Pain Treatment Care Plan Patient Care Plans

3565 COPD Treatment Care Plan Patient Care Plans

3568 Physical/Occupational Therapy Discontinuance Correspondence

3573 Discharge Summary - Infirmary Data Base

25 of 42

1st 2nd3rd

4th 5th 6th

Form # TitleHist



3574 Discharge Orders - Infirmary Prescriber's Orders

3580 A Acknowledgment Of Receipt Of CPAP, BIPAP, AUTOPAP Correspondence

3584 Inhaler Need Assessment Patient Care Plans

3585 Mental Health Pre-Release Summary PSU Record


Contacts

3586 Seizure Disorder Treatment Care Plan Patient Care Plans

3587 Palliative Care Program Interdisciplinary Team (IDT) Care Summary Patient Care Plans

3588 Vision/Hearing Screening Flow Sheets

3589 Admission History and Physical Examination - Infirmary Data Base

3590 Narcotic (OPIOID Analgesic) Chronic Pain Management Agreement Consents/ Refusals

3591 Medication Storage Consent/Refusal - MSDF Consents/ Refusals

3593

Informed Consent Relating to Risks Associated with use of Oral

Bisphosphonate Dental Record


DJC Documents

3593 S

Consentimiento Informado Sobre Los Riesgos Asociados Al Uso De

Bifosfonato Oral Dental Record


DJC Documents

3594 Professional Contact Questionnaire Mental Health PSU Record


Contacts

3605 Influenza Assessment Encounter - obsolete X (Progress Notes)

3606 H1N1 Screening Questionnaire Progress Notes

3611 Influenza Vaccination Screening Questionnaire Data Base

3611 S Cuestionario Para La Vacunacion Contra La Influenza Data Base

3612 Affidavit of Exraordinary Health Condition Miscellaneous

3613 Medical SummaryProblem List (file behind

DOC-3020)

3614 Activation/De-Activaton of Power of Attorney for Health Care

Active: Orig. - Active -


Problem List (on top of

Medical History or Legal

Documents/Consents/Out

side Reports

3615 Acknowledgment of Revocation of Power of Attorney for Health Care

Orig. - Miscellaneous;

Copy - Dental Record

(after DOC-3018) Medical History

3616

Acknowledgment of Revocation of Declaration to Physicians (file on

top of revoked DPH-00060, when present) Miscellaneous

3617

Patient Revocation of Declaration to Physicians (file on top of

Revoked DPH-00060, when present) Miscellaneous

3618

Patient Revocation of Power of Attorney for Health Care (POAHC)

(file on top of revoked POAHC, when present) Miscellaneous

3619 Transfer of Care Referral and Report Correspondence

26 of 42

1st 2nd3rd

4th 5th 6th

Form # TitleHist



3620 Paraplegia/ Quadriplegia Flow Sheet Flow Sheets

3621 Respiratory Care Plan Patient Care Plans

3622 Patient Communication Correspondence

3626

Dental Evaluation for Obstructive Sleep Apnea - file location


3626 Dental Evaluation for Obstructive Sleep Apnea Dental Record Treatment Notes

3627

Informed Consent for the Treatment of Obstructive Sleep Apnea with

Oral Applications - file location changed X (Dental Record) (Diagnosis/ Treatment)

3627

Informed Consent for the Treatment of Obstructive Sleep Apnea with

Oral Applications Dental Record


DJC Documents

3627 S

Consentimiento Informado Para El Tratamiento De La Apnea

obstructiva Del Sueno Con Aparatos Bucales Dental Record


DJC Documents

3627 S

Consentimiento Informado Para El Tratamiento De La Apnea

obstructiva Del Sueno Con Aparatos Bucales - file location changed X (Dental Record) (Diagnosis/ Treatment)

3628 TAP-3 Oral Appliance Delivery Checklist-file location changed X (Dental Record) (Diagnosis/ Treatment)

3628 TAP-3 Oral Appliance Delivery Checklist Dental Record Treatment Notes

3629

TAP-3 Oral Appliance Follow-Up Questionnaire - file location


3629 TAP-3 Oral Appliance Follow-Up Questionnaire Dental Record Treatment Notes

3631 Infirmary Medication Reconciliation Record Prescriber's Orders

3632 Monarch Special Management Unit (MSMU) Treatment Plan

PSU Record and


(Copies)


Contacts

3635 Nursing Admission Assessment - Infirmary Data Base

3636 Intake Medical Clearance Questionnaire (behind DOC-3018) Data Base

3639 Nursing Encounter Protocols Progress Notes

3640

Health Recommendations Upon Release/ Discharge of Female

Youth Correspondence

3641 Monarch Special Management Unit (MSMU) Discharge Plan

PSU Record and


(Copies)


Contacts

3642 Behavioral Management Plan

PSU Record and


(Copies)


Contacts

3642 A Behavioral Management Plan



(Copies)


Contacts

3643 Sleep Study Evaluation Tool Patient Care Plans

3645 Infirmary Patient Kardex Patient Care Plans

3646 Infirmary RN Assessment - obsolete X Flow Sheets

27 of 42

1st 2nd3rd

4th 5th 6th

Form # TitleHist



3647 Monthly Nursing Summary Flow Sheet - obsolete X Flow Sheets

3648 Dental Pain/Swelling/Bleeding Encounter Progress Notes

3648 Dental Pain/ Swelling/ Bleeding EncounterProgress Notes or

Dental Record Correspondence

3658 Mental Health Group Progress Notes PSU Record


Contacts

3659 Mental Health Brief Notes PSU Record


Contacts

3660

Challenge Incarceration Program (CIP) Exercise Injury Rehab

Instruction Correspondence

3661 Authorization for Chronic Opioid Use Consultations

3663 General Population Treatment Plan

Original: PSU Record;

Copy: Psychological

Records (Copies) TBD

3664 Fall Assessment Tool Flow Sheets

3665 BPH/Prostate Symptom Flowsheet Flow Sheets

3665 A BPH/Prostate Symptom Score Sheet Flow Sheets

3667 Lab Monitoring Psychotropic Medication Patient Care Plans

3670

Memo from Health Service Unit Practitioner to Patient (not in

response to correspondence from patient) Correspondence

3676 Sickle Cell Disease Treatment Care Plan Patient Care Plans

3677 Peritoneal Dialysis Daily Flowsheet Flow Sheets

3678 Levothyroxine & TSH Monitoring Patient Care Plan Patient Care Plans

3679 Hemodialysis Exeercise Flow Sheet Pedal Cycle Flow Sheets

3680 Order/Return CPAP BIPAP AUTOPAP Correspondence

3681 Manual Exchange Dialysis Quiz Miscellaneous

3682 Liverty Cycler Training Test Miscellaneous

3683 Pertoneal Dialysis Prescprition Form Prescriber's Orders

3684 Peritoneal Dialysis Monthly Clinic Visit Progress Notes

3685 Anemia Management Flow Sheets

3687 CRIT-Line Monitor Flowsheet Flow Sheets

3689 Inmate Worker Abilities and Limitations PSU Record Psychological Reports

28 of 42

1st 2nd3rd

4th 5th 6th

Form # TitleHist



3690 Infirmary Restorative Flowsheet Flow Sheets

3693 Victim Disclosures (Preparation for Polygraph) PSU Record SOT/Ch.980

3694 PTSD Screen PSU Record


Contacts

3695 Notice Of Need For Interpretor-For Off-Site Medical Care Correspondence

3696 Consent To Follow Hemodialysis Rules Consents/ Refusals

3697 Peritoneal Dialysis Cell Visit Checklist Miscellaneous

3698 Peritoneal Dialysis CAPD Training Release Form Miscellaneous

3699 Peritoneal Dialysis CCPD Training Release Form Miscellaneous

3700 CAPD Training Check List Miscellaneous

3701 CCPD Cycler Training Check List Miscellaneous

3702 Chronic Condition Treatment Care Plan Patient Care Plans

3707 Patient Care Plan for Volunteers Flow Sheets

3718 Transplant Evaluation LogData Base- after DOC-

3589

CCA 13-16

A Initial Health Screening Form Data Base

CCA 13-16

C Inmate Health Appraisal Form Data Base

CCA 13-16

I Medical Transport/Information/ Payment Request Form Consultations

CCA 13-17

A Intake Mental Health Screening Form Psychiatric Services

CCA 13-17

B Mental Health Evaluation Psychiatric Services

CCA 13-40

A Inmate/ Resident Health Appraisal Form Data Base

CCA 13-42

A Pre-Segregation Health Evaluation Flow Sheets

CCA 13-50

A Initial Health Screening Form Data Base

CCA 13-58

A Inmate/ Resident Consult Report from Provider Consultations

CCA 13-6

C1 Diabetes Clinic - Initial Visit Progress Notes

CCA 13-6

D2 Hypertension Clinic - Follow up visit Progress Notes

CCA 13-61

C Mental Health Treatment Plan Patient Care Plans

29 of 42

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4th 5th 6th

Form # TitleHist



CCA 13-64

B Offsite Transportation Information/ Payment Request Form Consultations

CCA 13-69

A Observation Monitoring Form Flow Sheets

CCA 13-85

A Therapeutic Diet Request Data Base

CCA 13-86

A Transfer Screening Form Data Base

CCA 13-87

C Immunization TB/ Record Data Base

CCA 13-87

E Inmate/Resident Initial and Annual Symptom Screening Data Base

DOH 4338

Wisconsin Human Immunodeficiency Virus (HIV) Infection

Confidential Case Report Correspondence

DPH 0060 Living Will (Declaration to Physicians)

Active - Right Side in

front of Problem List;

Deactive - Miscellaneous

DPH 0085 Power of Attorney for Health Care


Problem List - active;

Miscellaneous when

DPH -4151 Acute and Communicable Disease Case Report Correspondence

DPH -4243

Sexually Transmitted Diseases Morbidity and Epidemiologic Case

Report Correspondence

DPH 4763 Do Not Resuscitate


Problem List - active;

Miscellaneous when

DPH 7119 Ambulance Report Consultations

F-00038 Agreement for Coping Skills Program at WRC PSU Record

Legal Documents/

Consents/ Outside

Reports

F-00069 WRC Participation Agreement PSU Record

Legal Documents/

Consents/ Outside

Reports

F-00215 A Medication Adminstration Record - Colonoscopy Prep Orders Prescriber's Orders

F-00578 Progress Note-Primary Care Progress Notes

F-00578 A Primary Care- Intiial Physical Exam Data Base

F00600 Medical Nutrition Therapy-Progress Notes Data Base

F-00600 Medical Nutrition Therapy-Progress Notes Data Base

F-00775 Record Assembly Request

Consents/ Refusals

(attached to

authorization)

F-00879 Biopsychosocial Problem List

Orig - Problem List; copy

-Dental Record or PSU

Record

Legal Documents/

Consents/ Outside

Reports or Medical

History

F-0457 J Progress Note

Progress Notes (when

completed by HSU/PSU

staff)

F-20056 Urinalysis Request/ Report Laboratory Results

F-20057 Therapeutic Drug Assay Request/Report Laboratory Results

30 of 42

1st 2nd3rd

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Form # TitleHist



F-20058 Miscellaneous Chemistry Request/Report Laboratory Results

F-20059 Culture/ Susceptibility Request/Report Laboratory Results

F-20063 Hematology Request/Report Laboratory Results

F-20075 Refusal of Recommended Treatment/Test Consents/ Refusals

F-20106 On Unit Medication Record For Individual Medications

F-20126 Inmate/Patient Accident/Injury Report - not filed in chart (Shred Copy) WRC - HSU

F-20135 Annual Report for Known Positive TB Skin Test Data Base

F-20148

Individualized Treatment Plan - Problem Identification and Long-

Term Goals PSU Record

Legal Documents/

Consents/ Outside

Reports

F-20148 D Safety/Security Precautions Correspondence

F-20159 Medical Restrictions / Special Needs Correspondence

F-20159

Inmate/ Patient Health Care Monitoring/ Intervention Notification-

NAME CHANGE X (Correspondence)

F-20172 Medication/ Treatment Record - obsolete X (Medications Record)

F-20179 Conference SummaryPsychiatric Services or

PSU Record

Legal Documents/

Consents/ Outside

Reports

F-20195 Data Base - Social Service (Shred Copy) Social Service File

F-20195 A Initial Assessment - Social Service - not filed in chart (Shred Copy) Social Service File

F-20227 B Assessment Pain Scale Brief Inventory Progress Notes

F-20284 Dental Diagnosis/ Treatment Record Dental Record Treatment Notes

F-20284 Dental Diagnosis/ Treatment Record - file location changed X (Dental Record) (Diagnosis/ Treatment)

F-20286 Dental Examination and Record Chart - file location changed X (Dental Record) (Diagnosis/ Treatment)

F-20286 Dental Examination and Record Chart Dental Record Oral Examination

F-20289 Consent - Treatment/Surgical Procedure Consents/ Refusals

F-20457 I Progree Notes- Nursing Report Progress Notes

F-20473 Electronencephalographic Request Medical Imaging

F-20549 Consent for Psychological Assessment and Evaluation PSU Record

Legal Documents/

Consents/ Outside

Reports

F-20556 Progress Notes - Psychiatric (first document under divider) Psychiatric Services

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Form # TitleHist



F-20556 B Psychiatric Report - Update Note

Orig. -Psychiatric

Services, copy- PSU

Record

Legal Documents/

Consents/ Outside

Reports

F-20556 C Psychiatric Report - Discharge

Orig. - Psychiatric

Services, copy- PSU

Record

Legal Documents/

Consents/ Outside

Reports

F-20556 D Psychiatric Report -Progress Notes

orig.- Psychiatric

Services, copy PSU

Record

Legal Documents/

Consents/ Outside

Reports

F-20557 Nursing Progress Notes Psychiatric Services

F-20589 Admission Care and Confidentiality Information Consents/ Refusals

F-20646 Nutritional Monitor Flow Sheets

F-20657 B Care Plan - Hunger Strike Patient Care Plans

F-20715 Review for Mental Health Placement - WRC Response PSU Record

Legal Documents/

Consents/ Outside

Reports

F-20960 Medical Emergency Report Progress Notes

F-21026 Protime/ Coumadin Record Medications Record

F-21095 Diet Flow Chart (if special diet ordered) Data Base

F-21095 A Diet Order Change - obsolete X (Data Base)

F-21097 Nutrition History and Assessment (if Dietician Consult ordered) Data Base

F-21180 Patient Release Record - not filed in chart (Shred Copy) Records Office

F-21211 X-Ray Report - Patient Medical Imaging

F-21212 Electronencephalogram Report Medical Imaging

F-21248 Data Base - Medical Data Base

F-21250 Initial Nursing Assessment Data Base

F-21271 General Medical And Psychiatric Discharge Checklist Psychiatric Services

F-21405 Property Inventory - not filed in chart (Shred Copy) Records Office

F-21500

Vocational Workshop Program Participation Evaluation Performance

Notes PSU Record

Legal Documents/

Consents/ Outside

Reports

F-21504 Consent/Refusal for Dental Services Dental Record


DJC Documents

F-21506 Assessment Packet-Admission

PSU Record and


(Copies)

Legal Documents/

Consents/ Outside

Reports

F-21818 A Dietary Teaching and Learning Record Miscellaneous

F-22728 End Stage Renal Disease Medical Evidence Report Miscellaneous

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Form # TitleHist



F-22750 Patient Care Information Correspondence

F-22750 A Patient Care Information Correspondence

F-23211 A Weight/ Height Record Flow Sheets

F-23386 Patient HIV Testing Consent/Denial Consents/ Refusals

F-23792 A Sleep Record Flow Sheets

F-24013 A Physical Exam-Male Data Base

F-24013 B Initial Health Assessment and Medical History Data Base

F-24214 Dyskinesia Identification Data Base

F-24214 Dyskinesia Identification Data Base

F-24277 Informed Consent for Medication Consents/ Refusals

F-24783 A Inmate Problem Rating Scale - obsolete X (PSU Record)

Legal Documents/

Consents/ Outside

Reports

F-24954 Psychological Brief Discharge Summary PSU Record

Legal Documents/

Consents/ Outside

Reports

F-25194 Vital Signs/ Height/ Weight Record Flow Sheets

F-25237 Medical Admission Evaluation Data Base

F-25322 Release Information - not filed in chart (Shred Copy) WRC-Gatehouse

F-25491 Drug Utilization Psychiatric Services

F-25507 A Assessment-Admitting Physician Data Base

F-25507 A Assessment-Admitting Physician - suffix changed to F-25507A X (Data Base)

F-25507 B Initial Psychiatric Assessment Psychiatric Services

F-25512 A Assessment - Neurological Check Flow Sheet Flow Sheets

F-25513 Health Service Requests Patient Request Folder

F-25596 Care Plan - Inmate - obsolete X (PSU Record)

(Legal Documents/

Consents/ Outside

Reports)

F-25596 B Initial Treatment Learning Plan - copyPatient Care Plans or

PSU Record

Legal Documents/

Consents/ Outside

Reports

F-25596 C Treatment Learning Plan/ Release Transfer Summary - Community Patient Care Plans

F-25596 C Treatment Learning Plan-Inmate Patient Care Plans

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Form # TitleHist



F-25596 D Release Transfer Summary - copyPatient Care Plans or

PSU Record

Legal Documents/

Consents/ Outside

Reports

F-25605 Discharge Instruction Correspondence

F-25610 A MJTC Transfer Summary Psychiatrist Psychiatric Services

F-25610 C MJTC Transfer Summary Nursing Correspondence

F-25623 Program Participation Evaluation Performance Notes PSU Record

Legal Documents/

Consents/ Outside

Reports

F-25623 B Program Participation Evaluation - Coping Skills PSU Record

Legal Documents/

Consents/ Outside

Reports

F-25636 INH Chemoprophylaxis Record Flow Sheets

F-25641 Optometric Examination Record Optical

F-25644 Initial Entrance Screening Data Base

F-25644 Initial Entrance Screening - DDE changed suffix X (Data Base)

F-25665 Psychological Admission Summary PSU Record

Legal Documents/

Consents/ Outside

Reports

F-25666 Psychological Assessment Report PSU Record

Legal Documents/

Consents/ Outside

Reports

F-25669 A Psychological Progress Notes (copy) PSU Record

Legal Documents/

Consents/ Outside

Reports

F-25672 Health Services Progress Notes Progress Notes

F-25674 Initial Social Services Assessment - not filed in chart (Shred Copy) Records Office

F-25674 A Assessment - Initial/ Social Services - Patient (copy) PSU Record

Legal Documents/

Consents/ Outside

Reports

F-25692

Patient Participation in Treatment Planning Session

Acknowledgment Consents/ Refusals

F-25693 G

Seclusion/ Restraint Justification and Authorization - used at Sand

Ridge Miscellaneous

F-25693 H Seclusion/ Restraint Status Checks - used at Sand Ridge Miscellaneous

F-25693 I Seclusion/ Restraint Progress Note - used at Sand Ridge Miscellaneous

F-25693 J Seclusion/ Restraint Assessment Notes - used at Sand Ridge Miscellaneous

F-25693 K Seclusion/ Restraint Progress Note - used at Sand Ridge Miscellaneous

F-25713 Social Services Chronological History Records - not filed in chart (Shred Copy) Social Service File

F-25819 Discharge SummaryPsychiatric Services or

PSU Record

Legal Documents/

Consents/ Outside

Reports

F-25820 Initial Assessment Psychiatric Services

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Form # TitleHist



F-25908 Health Transfer Summary Correspondence

F-25944 Modified Diet Order Data Base

F-25975 Assessment - Patient Health in Mechanical Restraints Flow Sheets

F-26010 Consultation Note - Medical Clinic Consultations

F-26025 Aftercare Plan on Discharge/Extended Home Visit Correspondence

F-26053 Meal Refusal Documentation - not filed in chart (Shred Copy)

WRC - Security

Office

F-26091 Personal Indicators For Care - not filed in chart (Shred Copy) WRC - HSU

F-26108 Sleep/ Rest Pattern Disruption Flow Sheets

F-26108 A Risk for Falls Patient Care Plans

F-26138 HCV Evaluation & Referral Care Plan Patient Care Plans

F-26138 A Hepatitis C Treatment Candidate, Psychiatrist Review Psychiatric Services

F-26138 B Hepatitis C (HCV) Treatment Consent Consents/ Refusals

F-26138 C Hepatitis C (HCV) Treatment Flow Sheet Flow Sheets

F-26139 Diabetes Mellitus Treatment Care Plan Patient Care Plans

F-26139 A Diabetic Annual Foot Examination Patient Care Plans

F-26139 B Diabetic Education Care Plan Patient Care Plans

F-26139 C Diabetic Log Flow Sheets

F-26140 HIV Positive Flow Sheet Flow Sheets

F-26141 Asthma Treatment Care Plan Patient Care Plans

F-26141 A Assessment - Asthma Patient Care Plans

F-26141 B Asthma Self - Management Care Plan Patient Care Plans

F-26142 Hypertension/ Dyslipidemia Treatment Care Plan-Adult Patient Care Plans

F-26142 A Assessment - Cardiovascular Risk Data Base

F-26142 B Flow Sheet - Vitals Flow Sheets

F-26143 Dental Service Requests - file location changed X (Dental Record) (Correspondence)

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Form # TitleHist



F-26143 Dental Service Requests Dental Record Dental Service Requests

F-42024 Vaccine Fahrenheit Temperature Log Flow Sheets

F-44000

Wisconsin Antituberculosis Therapy Program Initial Request for

Medication Correspondence

F-44264 AIDS Case Report Correspondence

F-44702 Vaccine Administration Record Consents/ Refusals

Admission History and Physical - Dictated - now DOC-3589 X (Data Base)

Adult ADHD Self-Report Scale (ASRS-vl.l) Symptom Checklist X (Shred Copy) N/A

Advance Directive: DNR, POA, Declaration to Physician Left Inside Cover

Advanced Directive Label Front Cover

AED Use Summary Medical Imaging

Allergies Label Left Inside Cover

Annual Review Data Base

Anti-Coagulant Therapy Label Left Inside Cover

Barium studies Medical Imaging

Biopsy Laboratory Results

Bladder Scan Medical Imaging

Body Composition Analyzer Medical Imaging

Canteen Items Ordered Correspondence

Cardiac Care Label Left Inside Cover

Cardiac Catheterization Procedure Medical Imaging

Care Plans: Other Patient Care Plans

Catheterization and Coronary Arteriography Medical Imaging

Central Pharmacy Level 1 Drug Interaction Notice Correspondence

Certificate of Completion - not filed in chart (Shred Copy) Shred

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Form # TitleHist



CES-D Scale PSU Record


Contacts

Clinical Restriction Notification Correspondence

Clozapine Prescription Access System - not filed in chart (Shred Copy) Shred

Colonoscopy Medical Imaging

Communicable Disease Division Laboratory Results

Confidential Memo DCI Primary Care Health Service Unit Correspondence

Confidential Psychological Information PSU Record

Legal Documents/

Consents/ Outside

Reports

Consideration for Special Handling-Memo Correspondence

Coronary Heart Disease (CHD) Score Sheet for Men Patient Care Plans

Correctional Mental Health Screen for Men CMHS-M - not filed in

chart (Shred Copy) Shred

Correspondence regarding patient between HSU/ PSU/ Central

Pharmacy (not addressed patient) Correspondence

Correspondence to patient from HSU/ PSU/ Central Pharmacy (not

in response to correspondence from patient) Correspondence

Court Documents and Orders terminated by court or expired Miscellaneous

Court Documents and Orders: Guardianship, Ch. 51 Commitment

and others for treatment, etc (only orders in effect)Right Side in front of

Problem List

Court Order Expires Label Front Cover

Court Ordered Evaluation/Treatment (in effect) PSU Record

Legal Documents/

Consents/ Outside

Reports

CT Scans Medical Imaging

Cytology/ Tissue Requisition Laboratory Results

DDES Progress Notes (WRC) PSU Record

Legal Documents/

Consents/ Outside

Reports

Deceased Label Front Cover

Dental Laboratory Work Authorization Dental Record

Laboratory/

Miscellaneous

Dental Service Requests for Juveniles-DJC - obsolete X (Dental Record) (Correspondence)

Diabetic Label Left Inside Cover

Diets - other Data Base

DJC Documents with cover sheets, stapled together PSU Record Psychological Reports

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Form # TitleHist



Domestic Violence Counseling Evaluation - OSCI PSU Record


Contacts

Dynacare Laboratories Request Canary Copy - not filed in chart (Shred Copy) Shred

Dyslipidemia Label Left Inside Cover

Echocardiology and Doppler Echo Report Medical Imaging

EEG Reports Medical Imaging

EKG/ ECG Reports Medical Imaging

EMG Medical Imaging

Glasses Order Forms Copies from Contract Vendors Optical Sleeve

Glasses Receipt Form Signed by Inmate Optical

Growth Charts Flow Sheets

Guardian of the Person Front Cover

Hard of Hearing Label Left Inside Cover

Health Evaluation Data Base

Health Service Requests - County Jails Patient Request Folder

Health Services Classification Data Base

Holter Monitor Consultations

HSU Inmate Hospitalization Notification (Shred Copy)

Hypertension Label Left Inside Cover

Infirmary Discharge Memo Data Base

Infirmary Discharge Summary, typed document - now DOC-3573 X (Data Base)

Infirmary Nursing Care Plan - DCI Patient Care Plans

Initial Medical Screening Data Base

Inmate Correspondence - Dental Dental Record Correspondence

Inmate Letters PSU Record Inmate Correspondence

Inmate Medical Screening Form - Jail Contract Data Base

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Form # TitleHist



Inmate Patient Orientation to DCI Infirmary - Unit 25 Correspondence

Inmate Retention Program (IRP) Cover Letter Correspondence

Institutional Converter - obsolete X (Data Base)

Inventory of Depressive Symptomatology (Self Report) - not filed in

chart X (Shred Copy) Shred

Jail Contract: Medical/Booking Questions Data Base

Jail Documentation - when prior to incarceration Miscellaneous

Lab results relating to urine/ blood/ stool/ cell/ tissue (non-numbered

forms/ reports) Laboratory Results

Laboratory Reports from Dynacare and other laboratories including

off-site such as UWHC Laboratory Results

Laboratory Reports related to completed DOC-3001 Laboratory Results

Legal Correspondence PSU Record Restricted Access

Letters of Guardianship (in effect) PSU Record

Legal Documents/

Consents/ Outside

Reports

Letters/notes FROM inmates TO health staff Patient Request Folder

Limited English Proficiency Label Front Cover

Limited Exam /Consultation Dental Record Correspondence

Limited Exam/Consultation (DCI Oral Surgeon) Dental Record Correspondence

Limited Vision Label Left Inside Cover

Lipid Profile Patient Care Plans

Mammogram Medical Imaging

Medical Alert Label Front Cover

Medical Diet Order Data Base

Medical Imaging reports related to completed DOC-3001 Medical Imaging

Medical Imaging Sleeve with Medical Imaging CD’sRight Side in front of

Problem List

Medical Memos between DOC health care providers Correspondence

Medication Administration Record (MAR) (CPS) Medications Record

Medication Information Form - memo Correspondence

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Form # TitleHist



Medication Tear Tags - no longer used X (Patient Request Folder)

MRA reports Medical Imaging

MRI Pre-Screening Form Consultations

MRI Reports Medical Imaging

Multi-Volume Chart Label Front Cover

Name Alert Label Front Cover

Nuclear medicine reports Medical Imaging

Offender Face Sheet - no longer filed in chart X (Data Base)

Offender name labels - sheet


Problem List or Dental

Record

Laboratory/

Miscellaneous

Officer Receipt of Controlled Medications Record - not filed in chart (Shred Copy) HSM

Out of State Health Screening Checklist - name change X (Data Base)

Panoramic X-Rays Dental Record

Inside Front Cover

Pocket

Paternity Court Order Miscellaneous

Patient has BLUE Infirmary Chart Label Front Cover

Patient has RED Hemodialysis Chart Label Front Cover

Patient has RED Hemodialysis Chart Label Flow Sheets

Patient Health Questionnaire (PHQ-9) - not filed in chart X (Shred Copy) Shred

Perfusion Study/Scans Medical Imaging

Periodontal Screening Examination Dental Record Treatment Notes

Periodontal Screening Examination - file location changed X (Dental Record) (Diagnosis/ Treatment)

Perpetual Inventory Delivery Record - not filed in chart (Shred Copy) HSM

PET Scans Medical Imaging

Plastic pocket (UW ID card, Rolodex cards) - no longer placed in the

chart X (Left Inside Cover)

Police Reports (copy) PSU Record Restricted Access

Polysomnogram Report - UW Medical Imaging

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Form # TitleHist



Potential Drug Interaction Correspondence

Premedicate Label Left Inside Cover

Pre-sentence Investigation Reports (copy) PSU Record Restricted Access

Psychiatric Services Referral Correspondence

Psychological Services Progress Notes PSU Record Psychological Reports

Psychological Test Instruments (copyrighted/proprietary) PSU Record Restricted Access

Psychological Test Results and Reports (do not file test instrument

here unless it cannot be separated from results/report PSU Record Psychological Reports

Pulmonary Function (FV) Medical Imaging

Receiving Medical Screening Data Base

Respiratory Condition Label Left Inside Cover

Retrieval Information (PSU) PSU Record

Legal Documents/

Consents/ Outside

Reports

Retrieval Information/ collateral Information from off-site providers

prior to incarceration/ commitment: all documents Miscellaneous

Review Summary (for Class III-electronically) (McKesson) Consultations

SCI Medical Restrictions/Special Needs Committee Memo (Shred Copy)

Seizure Disorder Label Left Inside Cover

Sex Offender Assignments PSU Record SOT/Ch.980

Sex Offender Session Logs/Assignments PSU Record SOT/Ch.980

Spirometry Test Medical Imaging

Surgical ConsentDental Record- not filed

in chart

Taycheedah Intake Forms (no longer used) Data Base

TB Summary Report - WRC Data Base

Temporary File Label Front Cover

Texas Uniform Health Status Update Data Base

Tinea Versicolor-Teaching Sheet Correspondence

Trans-Telephonic Arrhythmia Monitor Report Medical Imaging

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Form # TitleHist



Treatment Plans/ Multidisciplinary Notes/ Other Progress Notes PSU Record


Contacts

Treatment Summaries PSU Record Psychological Reports

Tuberculin Test Records Data Base

Tuberculosis Questionnaire Data Base

Ultrasound Reports Medical Imaging

Victim Statements (copy) PSU Record Restricted Access

Visual Field Charts Optical

Wisconsin Immunization Registry (print-out from the website) Data Base

X-Ray Report Medical Imaging

X-Rays stored mounted or in coin envelopes -Dental Dental Record

Inside Front Cover

Pocket

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